Effective record-keeping is essential to health care. This book is a handy pocket-sized guide to keeping good health records that treats the process as an integral part of your everyday practice.

Every healthcare practitioner is expected to record their interactions with a patient in the patient’s health record, and this pocket guide is full of practical detail about: what a health record is and what its purpose ishow health records are managedwho has access to health recordsthe importance of maintaining a patient's health recordbest practice in keeping records Written by an experienced lecturer with input provided by current nursing students, this guidance is produced with you in mind – and you can carry it with you at all times! ContentsPreface; About the author; Acknowledgements; Common terminology and key concepts 1. Health records 1.

1 Defining health records 1. 2 The purpose of health records 1.

3 Components of a health record 2. Management of health records 2.

1 Confidentiality of health records 2. 2 Ownership of health records 2.

3 Storage of health records 2. 4 Retention periods 2.

5 Destruction of health records 3. Access to health records 3.

1 Patients reading their own health records 3. 2 Accessing health records 3.

3 Child patients and access to health records 3. 4 Accessing health records after the death of a patient 3.

5 Concerns about providing access to a patient's health record 4. The standard for record-keeping 4.

1 A standard for maintaining health records 4. 2 Features of good record-keeping 5.

Practical aspects of health records 5. 1 Considerations when writing an entry in a health record 5.

2 Time pressures 5. 3 Writing entries for colleagues 5.

4 Changing an entry in a health record 5. 5 Third party information 6.

Best practice in record-keeping 6. 1 Best practice pointers 6.

2 A process for best practice 6. 3 My top tip for best practice in record-keeping References; Useful resources; Notes.